This article is part of a series on what the healthcare industry looks like one year after the novel coronavirus was declared a pandemic and life in the United States began to drastically change.
The U.S. has grappled with the coronavirus pandemic for one year now, a year that saw major health systems and community physicians alike scrambling to ramp up operations to care for the growing tide of COVID-19 patients.
But unlike large hospitals, which have remained on relatively stable footing, the competition for scarce supplies and federal aid paired with a catastrophic plummet in patient visits early in the year left independent primary care practices — many already operating on razor-thin margins — wheezing.
Now, the financial situation has improved for the private practices that survived 2020. But even as volumes recover, front-line doctors are still facing fresh challenges, including rising frustration that they've been excluded from the vaccine distribution process and worries about downstream effects from delayed care.
Sigh of relief as volumes bounce back
After a year of COVID-19 and months of struggling to make ends meet, many independent practices report they're no longer facing an immediate financial cliff.
Although expenses, including pricey personal protective equipment, are still high, volumes are almost entirely back to normal, aided in large part by telehealth, primary care physicians say.
Autumn Road Family Practice in Little Rock, Arkansas, had to lay off 12 employees in March following plummeting patient visits, and was facing an extremely precarious financial future. Now, the independent practice is at 85% to 90% of normal visit volumes, with more than a third of visits conducted virtually.
Autumn Road has been able to rehire every employee who wanted to return, and even added a new provider, thanks to strict cost control measures and congressional COVID-19 aid, practice administrator Tabitha Childers said.
Numerous small providers that survived the worst of the pandemic's financial effects are reporting solidifying volumes and, having cut unnecessary costs and lobbied for loans, are even using the extra cash to grow, adding more providers or value-adds to their offices.
Additionally, practices operating in the direct primary care model, where patients pay a subscription fee to a practice for a wide swath of primary care services and insurance isn't accepted, say they've seen rising demand from people in their communities wanting to sign up.
Michael Ciampi, who operates a family practice in South Portland, Maine, has seen a lot of interest in his DPC office, which currently has about 675 members. "My waiting list is four to six months," said Ciampi, who's been spacing out in-person visits for patient peace of mind and filling in the extra time with telehealth.
Family Medicine of Malta, a primary care practice in Saratoga County, New York, had to cut expenses and halt overtime early in the pandemic. Now, it's "completely fine," Marc Price, a physician at the practice, said, partially thanks to a new COVID-19 testing machine that's helped bring in some additional revenue. "We're back to decent volume, but it's still not as busy as it has been. But we're not facing an immediate threat of closure. If we have to maintain long term at this volume, we can."
Despite the optimism, however, independent practices are still very much in a holding pattern following months of depressed revenue and sky-high expenses. A study published in Health Affairs estimates U.S. primary care practices could have lost more than $15 billion in 2020.
And though data is spotty on medical closures during the pandemic, a late September survey of primary care practices conducted by the Larry A. Green Center and Primary Care Collaborative found 7% didn't think they could keep their doors open past December. Another survey conducted by the Physicians Foundation estimates 8% of all physician practices nationwide, independently-owned or otherwise, have closed due to COVID-19.
In addition, the Physicians Foundation survey found 72% of physicians said their income plummeted, 43% had to cut staff and 16% had already changed jobs or planned to within a year.
Professional Medical Associates in Enterprise, Alabama, had a 75% patient no-show rate last March that resulted in huge dings to its topline. A lot of that pressure had abated by July, but "we really are still in that holding pattern," PMA physician Beverly Jordan said, noting winter is normally her practice's busiest time of year, but volumes are sitting at about 80% of normal levels. "It was a rough year," she said.
'Our biggest struggle:' excluded from vaccine distribution
Despite rising economic stability, primary care doctors report mounting frustration from being left out of the vaccine rollout. The push has ramped up in recent weeks but faced criticism for being disjointed, with states and localities having widely varying strategies. However, most are excluding family physicians — especially those unaffiliated with a larger hospital or system.
Many say they registered with their state and local health departments first thing to disseminate the shots and simply haven't heard back, despite repeated efforts to get in touch and dozens of calls a day from patients desperate to get the vaccine.
Jeff Gold, who operates a primary care practice in Marblehead, Massachusetts, said he signed up with the state's public health agency to be an immunization site in December. But "we still haven't heard a damn thing. It's just a complete debacle," Gold said.
In lieu of primary care physicians, who often have relationships with patients spanning years if not decades, most state officials are focusing on massive vaccination sites, including stadiums or hospitals, along with major drugstore chains like CVS or Walgreens. Currently, large retail pharmacies are the only sites allowed shipments directly from the federal government.
"It's like instead of the first resort, which is what we should be, we end up being the last resort," Gold said.
Primary care doctors say the exclusion is illogical, as their offices administer roughly half of all adult vaccinations in the U.S. The country has given emergency authorization to two efficacious vaccines, Moderna's and Johnson & Johnson's, which don't require special freezers like the Pfizer-BioNTech shot, and which even small offices could easily store and administer.
Almost 90% of primary care clinicians want their practices to be a vaccination site, but only 22% are considered one by their health department or local health system, according to a survey conducted mid-February by Larry A. Green Center and PCC.
Autumn Road, open for half a century, registered the first day possible in Arkansas and hasn't heard back about when it might receive doses, if at all.
"Our biggest struggle right now is our patients are angry because we can't get the COVID vaccine," Childers said, noting the practice fields about 10 to 20 calls a day from patients about the shot. "Many of our patients have said we're not going to get it until we can get it from y'all."
Many practices are keeping an updated list of their highest-risk patients to contact and a plan to pivot to vaccine administration once they hear a shipment is on the way. Forty percent of PCC respondents said they had already invested significant time into trying to find a vaccine for their most vulnerable patients, even if they themselves aren't distributing it.
"We've been applying to get the vaccine since day one ... Patients are calling constantly. When should I get it? Where should I get it? Should I get it? We get dozens of calls a day," Family Medicine of Malta's Price said, noting he's filled out informational surveys from New York's health department about his ability to distribute the vaccine, but isn't sure that means they'll ever get it.
"It's more onus on us, and we still can't give it out," Price said.
"Our biggest struggle right now is our patients are angry because we can't get the COVID vaccine. Many of our patients have said we're not going to get it until we can get it from y'all."
Autumn Road Family Practice's practice administrator
Though the U.S. is now averaging more than 2 million shots a day, a number of high-risk and elderly Americans have yet to receive a coronavirus vaccine. Fewer than a third of seniors have been fully inoculated, despite accounting for four-fifths of all coronavirus-related deaths in the country, according to the CDC.
And it's nigh impossible for primary care physicians to keep track of which of their patients have been vaccinated and which haven't, because distribution sites — whether a retail pharmacy chain, a hospital or other location — don't notify them.
That's left doctors almost entirely out of the loop on a key aspect of their patients' health.
"Unless a patient tells us, we don't know who's been vaccinated, which is really unfortunate," Ciampi said, noting he estimates about 10% to 20% of his patients have been vaccinated — but just isn't sure. "You'd think they could have one more person send us an email or fax to the primary care provider's office, but that hasn't been part of their modus operandi at this point," he said.
A year's worth of stress
Vaccine quagmire aside, primary care physicians are also airing concerns about the ramifications of medical care delayed during COVID-19, saying they're already seeing some detrimental effects crop up. Mental health needs in particular have seen the greatest near-term rise, and front-line physicians themselves aren't immune following months of acute stress.
One in five U.S. adults report pushing off medical care during the pandemic, according to a research study conducted by Harvard T.H. Chan School of Public Health and the Robert Wood Johnson Foundation. Of that group, more than half said they experienced negative health consequences as a result.
"We've had a lot of increased complaints for anxiety and depression," and patients with chronic conditions — "people we'd normally see regularly — it took six, nine months to get them back in the office and it took a lot of convincing," Childers said.
Independent primary care physicians are reporting a similar emotional toll, as they've for a year now continued to deliver healthcare while facing grave financial pressure and little-to-no direct federal aid. On top of that, the doctors have had to combat rampant misinformation and educate their patients around thorny issues like testing, masks and now vaccinations — often to intense pushback.
"You can see the toll that a year's worth of stress has taken on people," Jordan said, noting the difficulty of keeping confused and fearful patients abreast with shifting public health guidelines and conflicting messaging, especially as the virus has been politicized. "Our physicians and staff feel we can do no right. No matter what they say or do, there's always someone with a different opinion who has a lot of distrust in medicine who's on the attack."
Despite the frustration and fatigue, primary care physicians are in a prime spot to address vaccine hesitancy. Eight out of 10 people are likely to rely on a doctor, nurse or other provider's advice when deciding whether or not to get a shot, according to the Kaiser Family Foundation, and three-fourths of primary care clinicians surveyed by Larry A. Green said their relationships with patients have been integral to addressing hesitancy.
A glimmer of hope is President Joe Biden's American Rescue Plan, which explicitly calls out the need to leverage primary care workers moving forward. But primary care doctors say they're fed up of being the last line of defense against COVID-19, when they should have been the linchpin of the U.S.'s pandemic response from the start.
"We're all suffering from COVID fatigue in some way. Everybody is. Everybody's frustrated, I totally get it," Gold said. "But the pattern of what I've seen during this whole thing just proves that primary care is devalued, in the grand scheme of things. We're made to not matter."